Part I – The Slopes
While enjoying a day on the ski slopes at Winter park the patient fell exiting the ski lift. Patient was able to get up unassisted however, as she adjusted her stance the knee “twisted” and she fell again resulting in an external rotation of the right knee. Patient reported no pain at this time, but due to instability she was transferred by Ski Patrol down the slope on a sled. For the patient’s body to maintain homeostasis throughout the duration of exposure to the extreme cold, thermo receptors within the skin activated sending signals to the hypothalamus. In turn the cutaneous blood vessels constricted and shivering commenced in an attempt to accumulate and produce additional body heat. (Minerva Union, 2011, 2). During the time of exposure to the extreme cold all distal extremities and any exposed tissues would be vulnerable to the occurrence of frostbite. (Minerva Union, 2011)
Part II – The Emergency Room
Upon arrival at the emergency room the patient was shivering which can be seen as an early indication of hypothermia. At this time the patient was instructed to remove her parka in an effort to avoid further heat loss, resulting from an accumulation of moisture from the conditions outdoors. To assist in regulation of homeostasis the patient was wrapped in blankets and given hot chocolate. Pulse was taken at the Dorsalis Pedis to check the patient’s circulatory response. (The EMT Spot, 2014, 7). Pain reported by the patient was localized to the medial surface of the right knee, noticeable inflammation present due to the leaking of fluids from compromised internal tissues. The patient’s presentation of symptoms are indicative to that of a potential medial collateral ligament and medial meniscus tear. (Healthline, 2014, 5). The medial meniscus articulates with the medial condyles of the tibia and femur.
Part III – The Mile High Clinic
An X-ray, of which the primary diagnostic focus is bone structure and density (SWOG, 2013, 1), was ordered for the patient. X-ray results although negative for fracture were positive for swelling further indicating the possibility of tendon or ligament damage. A Lachman Test was performed on the patient to test the integrity of the anterior cruciate ligament within the patient’s right knee. To determine integrity: “the knee is flexed at a 20-30° angle, the tibia is displaced anteriorly relative to the femur; a soft endpoint or greater than 4 mm of displacement is positive.” (Free Dictionary-Medical Dictionary, 2014, 1). (The Clinical Advisor, 2014)
Upon the positive results of the Lachman test, further examination confirmed injury to the medial collateral ligament as well. Patient was instructed to see an orthopedist, given crutches, a brace, and instructed to keep the leg elevated and use ice to further aid in the reduction of swelling and pain. Furthermore patient was instructed not to use heat, such as a heat pad or hot tub, as heat can result in vasodilatation leading to increased pain and swelling.
Part IV – Seeing the Orthopedic Surgeon #1
Upon arriving home the patient was seen by a local orthopedic surgeon. Although the patient previously had an x-ray, an MRI was ordered to obtain a clear and concise understanding of the impact of the ski accident on the internal soft tissue structures of the patient’s right knee. An MRI or magnetic resonance imaging, “combines a powerful magnet with radio waves and a computer to manipulate these magnetic elements and create highly detailed images of structures in the body.” (SWOG, 2013, 4) In comparison to an MRI, an X-ray is typically used to diagnose and assess bone degeneration or disease, fractures and dislocation. (SWOG, 2013, 1)
Age often plays a role in the healing process, as does the patient’s physical health. Typically younger patients have an increased regenerative capacity for healing as opposed to older patients who may present with osteoarthritis. Osteoarthritis is “the degeneration of cartilage and its underlying bone within a joint as well as bony overgrowth.” (CDC, 2011, 1) Patients with poor physical health and other complications may not always be a good candidate for reconstructive surgery. Although the patient in this case is 55, she presents as a good candidate for reconstructive surgery as a result of leading a fairly active life style and was referred to an orthopedic surgeon who performs such surgical procedures on a routine basis.
Part V – Seeing the Orthopedic Surgeon #2
Patient presents in good health and as an ideal candidate for surgery. Referred to “pre-hab” to have the knee and leg in the best possible shape prior to surgery. The knee is a synovial joint and can be further classified as a hinge joint as it allows movement in only one direction. Synovial joints are lined by a synovial membrane filled with fluid to support the joint and reduce friction. (Buzzle, 2014), 3). Tendons and ligaments composed of dense regular connective tissues hold the structures of the knee together.(eHealth Ideas, 2013)
The hamstring, sartorious, gracilis, and popliteus assist in producing flexion, whereas the “Quads” rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius contribute to producing extension. (Healthline, 2013, 4-5). With regard for the surgical repair of the patient’s ACL the synovial membrane would need to cut in order to operate on both the meniscus and ACL. In addition, the use of a tendon to replace the ligament is possible, as both are composed of collagenous connective tissues. (University of Michigan, (n.d.), 2). Prior to surgical intervention it is especially important that the patient’s knee is in the best physical shape as post-operatively the patient can expect to experience some degree of atrophy and loss of bone mass as a result of restricted and limited use of the surgically repaired joint and limb. (Healthline, 2014, 1). During post-operative healing the patella is likely to heal faster than the ACL, MCI and menisci, as it has access to the arterial blood supply. (KneeHipPain, n.d., 14). The cartilage and the ligaments will take longer to heal as they are avascular and contain little to no blood supply.
Scar tissue is a normal occurrence of the healing process, and is composed of fibrous connective tissue. “This tissue contains a fibrous protein called collagen, as well as long carbohydrate molecules called polysaccharides, water and cells called fibroblasts.” Scar tissue also known as adhesion, plays an important role in the healing process as its collagenous fibers bind to damaged tissues in an effort to reconnect the damaged fibers.
Part VI – Resolution
The body is an incredible mechanism, through homeostasis and feedback loops the body is often able to regulate and return itself to a state of equilibrium. This can be evidenced in the case of the patient, as when subjected to the extreme cold thermo-receptors in the skin activated signaling the hypothalamus, resulting in vasoconstriction and shivering as a method to create and conserve body heat. However, in some cases such as that of a torn ACL, the body is not always able to repair itself and surgical intervention may be deemed necessary. Still, throughout the post-operative healing process the body employs various methods of negative feedback to once again return to a state of equilibrium.
Buzzle. (2014). Synovial membrane. Retrieved from: http://www.buzzle.com/articles/synovial-membrane.html The Centers for Disease Control and Prevention. (2011). Osteoarthritis. Retrieved from: http://www.cdc.gov/arthritis/basics/osteoarthritis.htm The Clinical Advisor. (2014). [Photo of Lachman Test]. Retrieved from: http://www.clinicaladvisor.com/tests-to-assess-acl-rupture/slideshow/394/#0 eHealth Ideas. (2013). [Photo of Knee Anatomy Design]. Retrieved from: http://www.ehealthideas.com/2013/12/knee-anatomy-diagram.html The EMT Spot. (2014). The ultimate emt guide to vital signs. Retrieved from: http://theemtspot.com/2010/05/22/the-ultimate-emt-guide-to-vital-signs/ The
Free Dictionary. (2014). Medical dictionary. Retrieved from: http://medical-dictionary.thefreedictionary.com/Lachman+test Healthline. (2013). Knee muscle anatomy. Retrieved from: http://www.healthline.com/human-body-maps/knee-muscles#4/4294967045 Healthline. (2014). Muscle atrophy. Retrieved from: http://www.healthline.com/symptom/muscle-wasting Knee Hip Pain. (n.d.). The anatomy of the patella. Retrieved from: http://www.kneehippain.com/patient_pain_anatomy.php Minerva Union. (2011). Homeostasis basics. Retrieved from: http://minerva.union.edu/linthicw/homeo.htm Minerva Union. (2011). [Photo of Homeostasis Temperature Control]. Retrieved from: http://minerva.union.edu/linthicw/homeo.htm References
Southwest Orthopedic Group. (2013). What is the difference between x-rays, mri, and ct scans. Retrieved from: http://www.sworthogroup.com/general-orthopedic-faq/25-what-is-the-difference-between-x-rays-mri-and-ct-scan University of Michigan. (n.d.). Section 9: Ligament tendon structure. Retrieved from: http://www.umich.edu/~bme332/ch10ligten/bme332ligamenttendon.htm